Biological, analytical and experimental components of variance in a long-term study of plasma constituents in rat

Statistical analysis of variance was applied to data from determinations of 14 plasma constituents in 25 rats in order to evaluate the analytical, experimental and biological (inter-and intraindividual) component of variance. Blood was taken seven times in intervals of 8-10 days, the last one by catheter technique and the other by heart puncture. The analytical portion of variance was determined by the concurrent analysis of a pool plasma standard. The experimental component of variance was evaluated by the comparison of the variation of the catheter values with that of the pooled data from heart puncture. The coefficient of variation for the latter may be grouped into three categories: less than 10% for protein, Na+, K+, Ca2+; 10-20% for urea, phosphate and the enzymes as alanine aminotransferase, choline esterase, alkaline phosphatase and leucine arylamidase and 20-65% for the other enzymes lactate dehydrogenase, malate dehydrogenase, aspartate aminotransferase and creatine kinase. The results from the samples taken by catheter technique generally revealed the lower values for the mean as well as for the variance. It became evident that the procedure of heart puncture is afflicted with the most aggravating interference factors, thus accounting for most of the experimental component of variance. The observed differences between the single blood drawings, the non-Gaussian distribution for several constituents, and the interactions between the components of variance do not always fit for the statistical concept of additivity of the single components.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-acting morphine for pain control in paediatric oncology

BACKGROUND: Guidelines for treatment of paediatric cancer pain recommend the usage of long-acting morphine. However, published paediatric experience with this drug is restricted to 147 children not systematically evaluated, and thus insufficient. We aimed to systematically analyse the age-dependent effects and adverse effects of long-acting morphine in paediatric cancer patients. PROCEDURE: Ninety-five children aged 1 to 19 years were enrolled in a collaborative retrospective study conducted over seven-and-a-half years. Pain was scored according to a numeric rating scale (NRS, range 0 to 5), and the corresponding medication was recorded. RESULTS: In 83 children documentation period started during morphine treatment (71, oral long-acting; 1, rectal; 11, IV). Mean oral/equivalent morphine starting dose was 1.3 mg/kgbw/d (SD 0.9). Mean end dose was 2.8 mg/kgbw/d (SD 2.7). Infants aged < 7 years received the highest average dose (2.6 mg/kgbw/d, SD 2.8), while patients > 12 years received the lowest dose (1.4 mg/kgbw/d, SD 1.1). Median pain intensity decreased from score 1.0 (mean 1.2) NRS at the beginning to 0 (mean 0.6) NRS at the end. The proportion of patients scoring > 2 NRS (severe or most severe pain) under morphine treatment decreased from 26 to 12% (P = 0.08). In children > 12 years pruritus was frequently observed (23% of patients). In all age groups, there were no severe adverse effects during the study period. CONCLUSIONS: In paediatric haematology/oncology, pain control by oral long-acting morphine proved to be safe and effective even in the very young patients. The pharmacological properties of long-acting morphine are ideally suited for paediatric use, combining efficacy and compatibility.     

Organisierte Schmerztherapie im DRG-System

Multidisciplinary pain management in pain centers can only be guaranteed if the DRG reimbursement system takes into account the multiple risk factors. The German pain associations prospectively analyzed clinical and administrative (DRG-related) data sets (n=3943) of inpatient and day care pain treatment facilities. The index diagnoses of 84% of the patient sample were grouped into nine basic DRGs. The most frequent pain procedure code was 8-918 ("multimodal pain management"). The minimal length of stay for this code set to 7 days was 17.2 days for the study sample. The DRG grouper software 2003 categorized 68.6% of the patients into PCCL 0 despite the proven complexity of risks and secondary diseases. The mean case weight in the sample was set at about 1. The pain-related data set analyzing pain severity, chronicity, and its influence on various functions emphasizes the total severity and burden of disease and thus the necessity for multimodal pain management. The German pain societies carried the motion that a new complex ICD code for chronic pain (with biopsychosocial consequences) should be established in the German Modification of the ICD. The new ICD code F62.80 and the procedure code 8-918 had not yet been implemented into the German DRG algorithm. Due to modifications in DRG systematics and the DRG algorithm, to be activated in 2005, the procedure code 8-918 will now automatically trigger into four special basic pain DRGs corresponding to the index pain diagnosis.     

Enzyme activities in thoracic duct lymph and plasma of anaesthetized,conscious resting and exercising dogs

Summary The significance of changes in lymph flow for the extracellular distribution and transport of cellular enzymes and for the level of enzyme activities in plasma was investigated. Specimens of thoracic duct lymph were obtained from an extracorporal lymph shunt in anaesthetized, conscious resting and treadmill exercising dogs (6 km×h^–1 for 1 h) The activity of 10 enzymes and of protein content in lymph and plasma were studied, as well as lymph flow, lymphatic transport, and the lymph-plasma ratio of these compounds. Lactate, pH, and blood gases were monitored in venous blood. Lymph flow of 0.80 ml×min^–1 in anaesthetized dogs more than doubled (to 1.86 ml×min^–1) when the animals were conscious and resting. In anaesthetized dogs lymph enzyme activity was higher only for enzymes of predominately hepatic origin, such as choline esterase (CHE) and alanine aminoferase (ALAT), and was lower for aspartate aminotransferase (ASAT) and aldolase (ALD). In conscious dogs, due to activation of the skeletal muscle tissue pump, lymphatic transport of enzymes with rather high activity in skeletal muscle, and of protein, is significantly enhanced. Enzyme activities in plasma, however, did not differ between the groups. Lymph-plasma activity ratios higher than one were found for lactate dehydrogenase (LDH), malate dehydrogenase (MDH), ASAT, creatine kinase (CK), ALD, and phosphohexose isomerase (PHI). Exercise stimulated lymph flow up to 4.9 ml×min^–1, and increased the lymphatic activities of those enzymes with a lymph-plasma ratio higher than unity, these enzymes increasing in the plasma due to the highly increased lymphatic transport. It is concluded that exercise induced changes of enzyme activities in plasma do not necessarily require a pathological enzyme release, but can be explained fully for moderate exercise by the lymphatic influx of enzymes from the interstitial resting enzyme pool in muscle.Supported by the Deutsche Forschungsgemeinschaft     

Opioid switch in palliative care, opioid choice by clinical need and opioid availability.

Availability of different WHO-step 3 opioids has encouraged the discussion on their value and led to the concepts of opioid rotation. Rotation is suggested, when other measures fail to achieve optimal analgesia and tolerability in cancer pain treatment. Opioid use was assessed in a prospective cohort study of 412 palliative care patients from 14 inpatient and outpatient palliative care facilities in Germany. The most frequently used opioids at baseline were morphine and fentanyl. The most frequent changes in medication (N=106) occurred from oral to parenteral morphine. Only in 49 cases true switches to other long acting opioids were recorded. This is far less than expected from other reports. True switches and adverse side effects were found to occur more frequently in inpatients, while efficacy problems were more frequently recorded in outpatients. There was no correlation between the opioid used at baseline and switch frequency, but numbers of cases receiving other opioids than fentanyl or morphine were low. Reasons for and frequencies of changes in medication were found to be largely shaped by the setting reflecting patients' needs and clinical necessities. Recommendation of first line therapy and availability of opioid formulations define the frequency of opioid use. This impedes evaluation of specific differences between the opioids.     

Assessing a risk tailored intervention to prevent disabling low back pain - protocol of a cluster randomized controlled trial

Background  

Although most patients with low back pain (LBP) recover within a few weeks a significant proportion has recurrent episodes or will develop chronic low back pain. Several mainly psychosocial risk factors for developing chronic LBP have been identified. However, effects of preventive interventions aiming at behavioural risk factors and unfavourable cognitions have yielded inconsistent results. Risk tailored interventions may provide a cost efficient and effective means to take systematic account of the individual risk factors but evidence is lacking.     

Deutscher Schmerzfragebogen (DSF) und standardisierte Dokumentation mit KEDOQ-Schmerz

KEDOQ-Schmerz was developed by the German Pain Society (formerly DGSS) as a basic tool for documentation and quality management of pain therapy. It is planned to use KEDOQ-Schmerz as the data basis for nationwide, cross-sectional and independent scientific research in health services in Germany. With comparatively little effort, each participating institution (practices, pain clinics) will be able to provide quality control of their own diagnostic procedures and therapeutic effects by using benchmarking. In future KEDOQ-Schmerz will also be used as a method for external quality management in pain therapy in Germany.